Flashcards in Schizophrenia Deck (33)
What is psychosis?
Loss of contact with external reality, characterised by impaired perceptions and thought processes.
What is schizophrenia?
> Fragmentation of thoughts
>Splitting of thoughts from emotions
>Withdrawal from reality
What is the DSM criteria for Schizophrenia?
A. Two or more of the following psychotic symptoms for >1 month, need 1, 2 or 3:
3. Disorganised speech
4. Grossly disorganised/catatonic behaviour
5. Negative symptoms
B. Clinically sig dysfunctioning (with normal functioning prior to symptom onset)
C. Continuous signs of disturbance for >6mths - must include at least 1 month of psychotic symptoms
(May have gradual deterioration in functioning)
D. Not better accounted for by other diagnoses (Schizoaffective, substance, autism)
Subtypes of psychotic disorders?
• Schizotypal PD: eccentric ideas, not clearly delusional
• Brief Psychotic Disorder (sudden,
What are the positive symptoms of schizophrenia?
• Formal thought disorder
• Behavioural disturbances: Disorganised, catatonia, odd mvt/behav
• Lack of insight (97%)
What are the negative symptoms of schizophrenia?
(Neg symptoms --> poorer response to treatment)
• Social withdrawal (poor eye contact): Glass barrier
• Anhedonia: inability to experience joy
• Emotional blunting (66%): inappropriate emotional expression
• Amotivational (due to anhedonia)
• Poverty of speech
• Poverty of content: shallow/low
What are hallucinations, according to the DSM5?
Perception-like experiences that occur in absence of any external stimulus (vivid, clear, not under voluntary control)
• Occurs in clear/normal sensory experiences
• 75% of schizophrenia patients report experiencing hallucinations from all different sensory modes
What are the most common hallucinations reported from patients with schizophrenia?
60-70% report hearing voices (distinct from own thoughts)
- Voices inside head or coming from external sources
- Own thoughts spoken aloud (describing feeling/thinking, fears or worries)
- Can be comforting
- Derogatory or insulting voices
- Third person commentary
- Commands to perform unacceptable behaviours
What are cultural differences in hallucinations experienced?
Hallucinations occur in similar form across cultures, but there are differences in the content and its interpretation
What is a myth concerning aggression and schizophrenia, and what is the reality of this? What are risk factors for hostility?
Myth: Schizophrenics are highly dangerous
Reality: Schizophrenics not more aggressive than general population, but their management of behav is not as good.
- Younger males (history of violence)
- Non-adherence with medication
- Substance abuse
What are Delusions, according to the DSM5?
Delusions: False firmly beliefs despite what others believe and despite evidence to contrary
- Odd and bizarre: often uncharacteristic of person
- Often not culturally acceptable
Delusions typically categorised according to content and bizarreness
What are different types of delusions?
1. Paranoid/Persecutory Delusions: Fixed, false belief one is being harmed/persecuted by particular person/group
2. Delusions of Reference: Neutral event interpreted to have personal meaning for individual (e.g. TV reporter special message for person)
3. Grandiose Delusions: False belief that one has special powers, abilities, influence, achievements or another identity that typically relates to power/wealth/fame
4. Nihilistic Delusions: Belief that one bodily part/world does not exist, or has been destroyed
5. Delusions of Guilt: Personal responsibility for events
6. Jealousy delusions: Belief that partner is cheating on them
7. Erotomatic Delusions: False belief that patients' romantic feelings are reciprocated (often by famous other)
8. Misidentification Delusions:Identity of someone they know has been stolen
What is characterised as thought disorder?
Formal thought disorder: Disturbances in flow and/or form of speech (vs content, as in delusions)
What are the negative and positive symptoms of thought disorder?
Negative manifestations: Reduced stream of thoughts and poverty of speech
- Derailment: Quite change in topics
- Tangential: irrelevant responses
- Echolalia: Repeat what you're saying
- Word salad: Incomprehensible stream of words
- Neologicsms: Quirky use of words/meanings
What is characterised as disorganised behaviour?
Grossly disorganised and abnormal motor behaviour:
- Extreme negativism (resisting instructions)
- Immobility ("waxy flexibility")
- Catatonic excitement: Excessive purposeless physical activity
Peculiar voluntary movements (posture, repetition, grimacing)
- Mutism, echolalia, echopraxia, imitating speech, movement
EPIDEMIOLOGY: What is the prevalence of schizophrenia?
Lifetime prev: 1-2% (other disorders: 1-3%)
Male to Female ratio: 2:3 (slightly more women)
What is the age of onset for schizophrenia?
Typical onset: Late adolescence and early adulthood (tend to be later for women)
Onset typically preceded by gradual deterioration in functioning followed by appearance of more acute symptoms (but can be quite sudden)
Onset often coincides with a stressful time of life, further complicated by impact of schizophrenia
Early onset associated with poorer outcomes
What are characteristics of the course of schizophrenia?
1+ episodes with periods of normal (or near normal) functioning between episodes
- 66% difficulty with at least one daily living
Most remain chronically unwell with a deteriorating course
- 50% classified as unable to work
What are the four stages in the course of schizophrenia?
1. Prodromal stage: Gradual deterioration, but not too out of normal for problems
- Median length of symptom development ~2 years (highly variable)
2. Acute phase: more pronounced symptoms
- Response to treatment related to duration of untreated psychosis - longer untreated, worse the cond becomes
3. Early recovery phase
4. Late recovery phase: Reintegration
- 80-90% relapse within 2-5 years of treatment (usually due to stopping medication from feeling fine)
What are the good prognostic factors of schizophrenia?
- Good premorbid functioning
- Acute onset
- Later age of onset (females)
- Precipitating event (e.g. drug induced psychosis)
- Low substance use
- brief duration of active phase
- Absence of abnormal brain structure
- No family history of schizophrenia
What are the bad prognostic factors for schizophrenia?
- Poor premorbid condition
- Slow insidious onset
- Prominent negative symptoms
- Longer duration of untreated psychosis
- Slower/less complete recovery
- Lower SES
- Migrant status
- Social support network
- Younger onset age (often --> longer untreated)
What are the implicated etiological factors implicated in schizophrenia, and what are the complications in determining these factors?
- Diathesis-Stress Model
Complications: Not very well understood etiology
- Heterogenous range of disorders with common underlying biological vulnerability
What are the genetic factors of etiology for schizophrenia?
Degree of risk related to degree of genetic relatedness: Genes determine susceptibility, while disorder is triggered by other factors
- 7% for siblings
- 9% for children of one affected parent
- 46% for children with two affected parents
- 12% for dizygotic twins
- 44% for monozygotic twins
Adoption studies: Higher rates among children with biologically schizophrenic parents (19%) compared to children with no bio parents with schizophrenia (10%)
What are the biochemical factors of schizophrenia?
Dopamine hypothesis: Overproduction/oversensitivity of dopamine receptors
1. Excess L-Dopa in Parkinsons' precipitate psychotic episodes
2. Amphetamine (dopamine agonist) psychosis: Abnormally large responses to low amphetamine doses - suggests over-sensitivity rather than excessive dopamine level
3. Response to anti-dop. medication - effective in 60% with more impact on positive symptoms
4. Lack of impact on negative symptoms hints at two separate syndromes
- Positive symptoms: associated with dopamine activity
- Negative symptoms: associated with brain degeneration
What is the most consistent finding in patients with schizophrenia?
Enlarge ventricles in schizophrenia - relative size over 2x larger than normal controls --> brain tissue loss
Most likely cause is loss of brain tissue: chronic schizophrenia associated with brain abnormalities
What are the neuroanatomical factors associated with schizophrenia?
Brain atrophy in:
pFC (exec functioning) --> Negative symptoms
Smaller left hippocampal volume. Associated with:
- Those with high risk of developing schizophrenia
- No family history
Hard to determine direction of causality.
Structural brain abnormalities appear to predate onset of psychosis - worsens with progressive illness
- Early neurodevelopmental damage may play a key etiological role
What are some developmental factors associated with schizophrenia?
Birth trauma and maternal viral infections likely to contribute
- Timing of viral infections likely to impact
- Nutritional deficiencies may contribute to adverse neurological development
- Birth complications - 4x higher risk than for non-complicated births
- 10x greater likelihood in complicated caesarean birth
Seasonal variations and place of birth
- Greater likelihood in winter/spring birth - viral illnesses or vitamin D deficiency?
- two-fold increase in risk for urban births
- Low SES births (but drift hypothesis?)
Developmental course of schizophrenia?
(refer to diagram in notes)
Polygenic susceptibility --> Genetic disposition (high paternal age) --> Birth (Birth complications, viral infections, nutrition, Urban, winter/spring) --> Childhood (Childhood abuse, social stresses, urban upbringing) --> Early Adolescence (Drug use: Cannabis, Amphetamine) --> Late adolescence (idiopathic stress, social/education/work stresses) --> PSYCHOSIS ONSET (relapse, substance abuse) --> Treatment resistant disability
Range of internal intracychic factors + external stressors --> Trigger of psychosis
TREATMENT: What medicated treatments are available?
Medication: primary intervention. Blocks D2 and D3 dopamine receptors
- 60% of those with positive symptoms respond
- 10-20% do not show symptom improvement in response to medication
- Relapse rates high within one year (40%) - usually due to non-compliance